P. Anne Scott

Perceptions of Autonomy in the Care of Elderly People in Five European Countries

The focus of this article is perceptions of elderly patients and nurses regarding patients’ autonomy in nursing practice. Autonomy is empirically defined as having two components: information received/given as a prerequisite and decision making as the action. The results indicated differences between staff and patient perceptions of patient autonomy for both components in all five countries in which this survey was conducted. There were also differences between countries in the perceptions of patients and nurses regarding the frequency with which patients received information from nursing staff or were offered opportunities to make decisions. This is the second of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented.

Perceptions of Autonomy, Privacy and Informed Consent in the Care of Elderly People in Five European Countries: comparison and implications for the future:

This article discusses nurses’ and elderly patients’ perceptions of the realization of autonomy, privacy and informed consent in five European countries. Comparisons between the concepts and the countries indicated that both nurses and patients gave the highest ratings to privacy and the lowest to informed consent. There were differences between countries. According to the patient data, autonomy is best realized in Spain, privacy in the UK (Scotland), and informed consent in Finland. For the staff data, the best results tended to concentrate in the UK. The conceptual and methodological limitations of the study are identified and discussed. Implications of the results are divided into three areas: nursing practice, education and research. In practice, the analysis of patients’ values and the ethical sensitivity of nurses are important as part of ethically good care. In nurse education, students should learn to recognize ethical problems, generally and particularly, among vulnerable groups of patients. Multicultural international research is needed in this area. This is the last of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented.

Perceptions of Informed Consent in the Care of Elderly People in Five European Countries

The focus of this article is on elderly patients’ and nursing staff perceptions of informed consent in the care of elderly patients/residents in five European countries. The results suggest that patients and nurses differ in their views on how informed consent is implemented. Among elderly patients the highest frequency for securing informed consent was reported in Finland; the lowest was in Germany. In contrast, among nurses, the highest frequency was reported in the UK (Scotland) and the lowest in Finland. In a comparison of patients’ and nurses’ perceptions, nurses had more positive views than patients in all countries except Finland. Patients with less need for nursing interventions in Greece and Spain gave their consent less often. The German and Greek patients were older, and the results also point to an association between this and their lower frequency of giving consent. In Spain, patients who were married or who had a family member or friend to look after their personal affairs were more likely to be included in the group whose consent was sought less often. This is the fourth of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented.

Aristotle, Nursing and Health Care Ethics

Even a brief consideration of the nature of nursing will indicate that an ethical dimension underlies much, if not all, of nursing practice. It is therefore important that students and practitioners are facilitated in developing an ethical awareness and sensitivity from early in their professional development. This paper argues that Aristotelian virtue theory provides a practice-based focus for health care ethics for a number of reasons. Also, because of his emphasis on the character of the moral agent, and on the importance of perception and emotion in moral decision-making, Aristotelian virtue theory provides a useful supplement to the traditional duty-based approaches to health care ethics analysis, which are increasingly being identified in the literature as having limits to their application within the health care context.

Ethics Education and Nursing Practice

This paper suggests that a consideration of health care practice is a necessary step in gaining insight into the appropriate composition of an ethics course for students in the health care professional. Health care practice, if it responds to the needs of society, is dynamic in nature. In the current climate of change in the health service, the author sug gests that the nursing profession needs to become more proactive in analysing and attempting to determine the future shape of nursing. To protect patient care the nursing profession needs to have its eyes open to the ethical dimensions of changes in role and practice. The author argues that, in attempting to ensure that the education to which nursing students are exposed is of relevance, it is necessary to introduce an element of the ideal into the ethics component of their professional education. From early on in their profes sional development students should be aware of the scope and standards of practice, and the type of role enactment to which the profession requires them to aspire.

Missed care: A need for careful ethical discussion

Missed nursing care has received relatively little attention in the nursing literature up to and including the first decade of this century. However, this is now changing and missed care has recently been recognized as an interesting and urgent matter by a number of nurse researchers. The first study recognizing this issue (‘care left undone’) was reported by Aiken et al., and the first study examining the notion and reality of missed care was reported by Kalisch in 2006. Several national and international research groups and networks, such as the RANCARE Consortium and Missed Care Study Group, are currently working with the concept and phenomenon of missed care. The need for such research is evident from the point of view of the connection with staffing and work conditions, patient safety and nurse-sensitive patient outcomes among other issues. Missed care means any aspect of (nursing) care that is omitted or delayed, in part or in whole. Kalisch and Xie regarded missed care as an error, act of omission that leads to an adverse outcome or significant potential of such outcome. Thus, missed care can be seen as an outcome of activities and processes performed (or not performed), consciously or unconsciously, by professional nurses. Several synonyms or related terms for missed care have been used in the literature – terms such as ‘unmet care needs’ and ‘omitted care’. ‘Care left undone’, ‘delayed care’, ‘rationing of nursing care’, ‘covert rationing of nursing care’ or ‘implicit rationing of nursing care’ have been used especially in the context of limited resources to describe the activity of professional nurses. For example, Schubert et al. defined rationing in nursing in terms of ‘the withholding or failure to carry out necessary nursing tasks due to inadequate time, staffing level and skill mix’. Furthermore, many studies have shown that low Registered Nurse staffing levels is associated with reports of missed nursing care in hospitals. Research results also show that missed care is a common issue in nursing contexts, especially in acute care hospitals, where the topic has been studied most. Furthermore, reviews and many studies have revealed that the patterns of unfinished care were consistent with the subordination of patient education, comfort care and emotional support activities to those related to physiologic needs and organizational audits. From the ethics point of view, missed care as an outcome, and the processes leading to such an outcome, warrants closer examination. Decision-making and prioritization happens daily in nursing when nurses take care of many patients at the same time and, for example, the urgency of needs is different. There is need for close examination of this kind of decision-making and of the ethical elements inherent in such decisionmaking. Nurses may be either ethically aware or ‘ethically blind’ in such situations. Ethical elements and aspects are the most problematic when they are hidden. Although ethical awareness may lead to ethical

The Nurse as Patient Advocate

The need to act as an advocate for the patient, as an important part of the nurse’s role in the 21st Century, appears to be taken for granted; this is especially the case in the nursing literature, and in the British, Irish and international nurseing practice contexts. However while some nurse scholars, nursing registration bodies, professional organisations, and many practising nurses seem quite happy with the rhetoric of ‘nurse as patient advocate’ this is not an uncontroversial stance. A number of authors have challenged both the basis for the claim that nurses should be patient advocates, and the possibility of such a role for nurses.

Resource Allocation and Rationing in Nursing Care

Public discussion of resourcing in health care tend to compound ideas of resource allocation and rationing. Public debate also tends to focus on situations of scarcity such as lack of kidneys or hearts for transplantation, or heated arguments regarding whether the latest very expensive new drug should be made available, regardless of cost, to treat certain condition such as Cystic Fibrosis or a particular type of cancer. The idea that nursing or medical time is an important health care resource that needs to be allocated with care rarely gets an effective airing in public debate.

Key Concepts and Issues in Nursing Ethics

Nurses are important to patients. Nurses touch people’s lives during some of the peaks and troughs of human existence. Therefore it is important that we think about nurses and nursing. What do our patients require from nurses and how do we, as a society, as nurses, and as health service leaders, meet patient need? The first step is to recognise that nursing, as a practice, has moral values at its core. The nursepatient relationship, which is central to the provision of nursing care, has ethical importance and is of ethical significance. It is also vital to consider that the context within which nurses practice can shape and be shaped by the moral values of nursing. These moral values form what can be termed the ethical dimension of nursing. It is therefore important that we explore and examine these moral values. Codes of conduct are examples of the nursing profession’s collective attempt to express its underlying values. The institutions within which nurses work help or hinder the actual expression of these values in nursing practice and patient care. We need to recognise the interplay of these various factors in order to ensure that we as nurses, as potential patients, and as members of society understand what good nursing practice means, what it looks like in practice, and how it can be supported. This chapter sets out to identify the ethical domain of nursing practice, and signal its relevance for good nursing care and a safe, supportive patient experience. The chapters which follow provide theoretical and conceptual lenses through which to identify, analyse and discuss ethical issues in nursing practice, with a view to providing tools for the nurse to practice in an ethically sensitive and appropriate manner.

Nursing and the Ethical Dimension of Practice

Nurses are important to patients. Nurses touch people’s lives during some of the peaks and troughs of human existence. Therefore it is important that we think about nurses and nursing. What do our patients require from nurses and how do we, as a society, as nurses, and as health service leaders, meet patient need? The first step is to recognise that nursing, as a practice, has moral values at its core. The nurse-patient relationship, which is central to the provision of nursing care, has ethical importance and is of ethical significance. It is also vital to consider that the context within which nurses practice can shape and be shaped by the moral values of nursing. These moral values form what can be termed the ethical dimension of nursing. It is therefore important that we explore and examine these moral values. Codes of conduct are examples of the nursing profession’s collective attempt to express its underlying values. The institutions within which nurses work help or hinder the actual expression of these values in nursing practice and patient care. We need to recognise the interplay of these various factors in order to ensure that we as nurses, as potential patients, and as members of society understand what good nursing practice means, what it looks like in practice, and how it can be supported. This chapter sets out to identify the ethical domain of nursing practice, and signal its relevance for good nursing care and a safe, supportive patient experience. The chapters which follow provide theoretical and conceptual lenses through which to identify, analyse and discuss ethical issues in nursing practice, with a view to providing tools for the nurse to practice in an ethically sensitive and appropriate manner.